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Despite an increasing feminization of India's older population marked by a high incidence of widowhood among aged women, women's health in later life and the health consequences of widowhood has received little attention in the existing gender and gerontological scholarship in India. Based on data of a nationally representative survey by the National Sample Survey Organization (N = 34,831, ages 60 and over), this study analyzed marital status, gender, health and health care utilization, and examined the gendered nature of aging and widowhood in India. Significant differences were found in health status and utilization of health care services by gender and marital status. Widowed persons of either gender were found to be the most vulnerable and, overall, widows emerge as the most disadvantaged group. KEYWORDS aging, gender, marital status, India, health status, health care utilization DOI: 10.1080/15313204.2010.523650

With dramatic increases in antiretroviral therapy (ART) provision, many clinics in sub-Saharan Africa are congested, but little attention has focused on the efficiency of clinics. Between April and June 2008, we conducted a time-and-motion study to assess patient flow at three HIV clinics in Uganda. Mulago HIV Clinic had 6,700 active patients, compared with 2,700 at Mbarara Municipal Council Clinic (MMC) and 2,800 at Reachout Mbuya (ROM). Mulago had six doctors and eight nurses; MMC had two doctors and two nurses, and ROM had two doctors and 12 nurses. Mulago and MMC used a doctor-led model, whereas ROM used a nurse-led model. Randomly selected patients were tracked, with data collected on time waiting and time spent with providers. Patients were categorized as new, preparing for ART, early ART, stable ART, or non-ART. Doctors indicated whether the patients they saw warranted their consultation. Data were collected on 689 patients (230 at Mulago, 229 at MMC, and 230 at ROM). Overall waiting time was longest at ROM (274 rain; 209-346) and Mulago ISS (270 min; 230-336) compared with MMC (183 min; 148-233). Nurse-clinicians at ROM spent twice the time with patients compared with the doctors at Mulago. At Mulago, doctors indicated that 27% of the patients they reviewed did not need to see a doctor, compared with 45% at MMC. Task-shifting may not be efficient in terms of time. More-effective triage and longer visit intervals could improve patient flow and capacity for cost-effective scale-up. DOI: 10.1089/apc.2009.0328

Understanding the structural obstacles people face with regard to health has become an important area of intellectual and practical concern, particularly with vulnerable populations in low-income countries. This article documents some of the experiences of a little-documented, vulnerable population--Haitian agricultural workers, or braceros, on the bateyes (primarily Haitian communities) of the Cibao region of the Dominican Republic. The qualitative data presented here draw from a sample of Haitian agricultural workers (N=370) living in six different batey communities. Geographic segregation, access to transportation, occupational and environmental health challenges, and negative treatment by doctors and other health professionals--all expressions of structural violence--emerged as salient impediments to health and well-being. Structural violence, especially through the mechanism of anti-Haitianism, works to both create environments that undermine the well-being of Haitian agricultural workers and, when seeking treatment, can limit opportunities for access to care. Key words: structural violence, Haitians, bateyes, Dominican Republic, health

IN BRAZIL, recent regulations require changes in private and public health systems to make special services available to deaf patients. In the present article, the researchers analyze the perceptions of 25 sign language-using patients regarding this assistance. The researchers found communication difficulties between these patients and health services staff, as well as a culture clash and a harmful inability among the service providers to distinguish among the roles of companions, caretakers, and professional translator/interpreters. Thus, it became common for the patients to experience prejudice in the course of treatment and information exchange, damage to their autonomy, limits on their access to services, and reduced efficacy of therapy. The researchers conclude that many issues must be dealt with if such barriers to health access are to be overcome, in particular the worrying degree of exclusion of deaf patients from health care systems.

Objectives. We sought to determine whether aggregate national data for American Indians/Alaska Natives (AIANs) mask geographic variation and substantial subnational disparities in prenatal care utilization. Methods. We used data for US births from 1995 to 1997 and from 2000 to 2002 to examine prenatal care utilization among AIAN and non-Hispanic White mothers. The indicators we studied were late entry into prenatal care and inadequate utilization of prenatal care. We calculated rates and disparities for each indicator at the national, regional, and state levels, and we examined whether estimates for regions and states differed significantly from national estimates. We then estimated state-specific changes in prevalence rates and disparity rates over time. Results. Prenatal care utilization varied by region and state for AIANs and non-Hispanic Whites. In the 12 states with the largest AIAN birth populations, disparities varied dramatically. In addition, some states demonstrated substantial reductions in disparities over time, and other states showed significant increases in disparities. Conclusions. Substantive conclusions about AIAN health care disparities should be geographically specific, and conclusions drawn at the national level may be unsuitable for policymaking and intervention at state and local levels. Efforts to accommodate the geographically specific data needs of AIAN health researchers and others interested in state-level comparisons are warranted. (Am J Public Health. 2010;100:122-128. doi: 10.2105/AJPH.2008.148908)

An impressive body of public health knowledge on health care disparities among Latinos has been produced. However, inconclusive and conflicting results on predictors of health care disparities remain. We examined the theoretical assumptions and methodological limitations of acculturation research in understanding Latino health care disparities, the evidence for socioeconomic position as a predictor of health care disparities, and the effectiveness of cultural competency practice. Persistent use of culture-driven acculturation models decenters social determinants of health as key factors in health disparities and diminishes the effectiveness of cultural competency practice. Social and economic determinants are more important predictors than isculture in understanding health care disparities. Improvements in the material conditions of low-income Latinos can effectively reduce health care disparities. (Am J Public Health. 2010;100:18-23.doi: 10.2105/AJPH.2008.138826)

In the United States, the publically supported national HIV medical care system is designed to provide HIV medical care to those who would otherwise not receive such care. Nevertheless, many HIV-infected persons are not receiving medical care. Limited information is available from HIV-infected persons not currently in care about the reasons they are not receiving care. From November 2006 to February 2007, we conducted five focus groups at community-based organizations and health departments in five U.S. cities to elicit qualitative information about barriers to entering HIV care. The 37 participants were mostly male (n = 29), over the age of 30 (n = 34), and all but one had not received HIV medical care in the previous 6 months. The focus group discussions revealed health belief-related barriers that have often been overlooked by studies of access to care. Three key themes emerged: avoidance and disbelief of HIV serostatus, conceptions of illness and appropriate health care, and negative experiences with, and distrust of, health care. Our findings point to the potentially important influence of these health-related beliefs on individual decisions about whether to access HIV medical care. We also discuss the implications of these beliefs for provider--patient communication, and suggest that providers frame their communications with patients such that they are attentive to the issues identified by our respondents, to better engage patients as partners in the treatment process.

Data repeatedly demonstrate that HIV-infected people who regularly utilize primary health care services are more likely to have access to lifesaving treatments (including antiretroviral medications); have better indicators of health status; survive longer; and use acute care services far less. Women tend to have poorer HIV outcomes than men, which is likely due to gender disparities in optimal utilization of HIV primary care services. To understand the relationship between gender and the HIV health care system, we collected interview and medical record data between August 12, 2004 and June 7, 2005 from 414 severely marginalized, HIV-infected people in New York City and examined whether gender-related disparities in HIV health care utilization existed, and, if so, whether these patterns were explained by patient sociodemographic/behavioral characteristics and/or attitudes toward the health care system and providers. Women were significantly less likely to have optimal HIV health care services utilization, including lower use of HIV primary care services (odds ratio [OR] = 0.56, 95% confidence interval [CI] = 0.35, 0.90) and greater use of the emergency department (OR = 2.13, 95% CI = 1.31, 3.46). Although we identified several factors associated with suboptimal HIV health care services utilization patterns in addition to female gender (low education, insurance status, mistrust of the health care system, and poor trust in health care providers), we were unable to identify factors that explained the observed gender disparities. We conclude that gender disparities in HIV health care utilization are due to a complex array of factors, which require more qualitative and quantitative research attention. Development of intervention strategies that specifically target severely disadvantaged women's HIV health care utilization is in great need.

Objectives. We sought to disentangle the relationships between race/ethnicity, socioeconomic status (SES), and unmet medical care needs. Methods. Data from the 2003-2004 Community Tracking Study Household Survey were used to examine associations between unmet medical needs and SES among African American and White women. Results. No significant racial/ethnic differences in unmet medical needs (24.8% of Whites, 25.9% of African Americans; P=.59) were detected in bivariate analyses. However, among women with 12 years of education or less, African Americans were less likely than were Whites to report unmet needs (odds ratio [OR] = 0.57; 95% confidence interval [CI] =0.42, 0.79). Relative to African American women with 12 years of education or less, the odds of unmet needs were 1.69 (95% CI = 1.24, 2.31) and 2.18 (95% CI = 1.25, 3.82) among Africa n American women with 13 to 15 years of education and 16 years of education or more, respectively. In contrast, the relationship between educational level and unmet needs was nonsignificant among White women. Conclusions. Among African American women, the failure to recognize unmet medical needs is related to educational attainment and may be ah important driver of health disparities, representing a fruitful area for future interventions. (doi:10.2105/AJPH.2008.154088)

Problem High out-of-pocket payments and user fees with unfunded exemptions limit access to health services for the poor. Health equity funds (HEF) emerged in Cambodia as a strategic purchasing mechanism used to fund exemptions and reduce the burden of health-care costs on people on very Iow incomes. Their impact on access to health services must be carefully examined. Approach Evidence from the field is examined to define barriers to access, analyse the role played by HEF and identify how HEF address these barriers. Local setting Two-thirds of total health expenditure consists of patients' out-of-pocket spending at the time of care, mainly for self-medication and private services. While the private sector attracts most out-of-pocket spending, user fees remain a barrier to access to public services for people on very low incomes. Relevant changes HEF brought new patients to public facilities, satisfying some unmet health-care needs. There was no perceived stigma for HEF patients but many of them still had to borrow money to access health care. Lessons learned HEF are a purchasing mechanism in the Cambodian health-care system. They exercise four essential roles: financing, community support, quality assurance and policy dialogue. These roles respond to the main barriers to access to health services. The impact is greatest where a third-party arrangement is in place. A strong and supportive policy environment is needed for the HEF to exercise their active purchasing role fully. Obstacles a l'acces aux services medicaux et fonction d'achat des fonds de financement de la sante: enseignements provenant du Cambodge Problematique Le montant eleve des depenses et des participations financieres a la charge des usagers et l'absence de financement des exemptions pour ces depenses limitent l'acces aux services de sante pour la population pauvre. Des Fonds de financement de la sante (Health Equity Fonds, HEF) sont apparus au Cambodge en tant que mecanismes strategiques d'achat servant a financer ces exemptions et a reduire la charge liee aux soins medicaux pour les personnes a tres faibles revenus. Leur impact sur l'acces aux services de sante doit etre examine de maniere approfondie. Demarche Les elements provenant du terrain sont examines pour identifier les obstacles a l'acces aux services, analyser le role joue par les fonds HEF et determiner comment ils aplanissent ces obstacles. Contexte local Deux tiers des depenses de sante totales correspondent a des debours a la charge des patients au moment des soins, resultant principalement de l'automedication et du recours aux services de sante prives. Si le secteur prive est a l'origine de la plupart des depenses de sante a la charge des patients, les participations financieres a la charge des usagers restent un obstacle a l'acces aux services publics, pour les personnes tres pauvres. Modifications pertinentes Les fonds HEF ont amene de nouveaux patients dans les etablissements de sante publics, repondant ainsi a une partie des besoins en soins medicaux insatisfaits. On n'a observe aucune stigmatisation a l'egard des patients soignes grace aux fonds HEF, mais nombre d'entre eux ont du encore emprunter de l'argent pour acceder aux soins. Enseignements tires Les fonds HEF constituent un mecanisme d'achat dans le cadre du systeme de sante cambodgien. Ces fonds exercent quatre roles essentiels : financement, soutien aux communautes, assurance de la qualite et dialogue politique. Ces roles repondent aux principaux obstacles a l'acces aux services de sante. L'impact des fonds est maximal lorsqu'un dispositif impliquant une tierce partie est en place. Pour que les HEF exercent pleinement et activement leur fonction de mecanisme d'acquisition, un environnement politique solide et favorable est necessaire. Problema La elevada cuantia de los pagos directos y los honorarios pagados por los usuarios y las exenciones de cobertura limitan el acceso de los pobres a los servicios de salud. Los fondos de inversion en acciones para la salud (FIAS) surgieron en Camboya como un mecanismo de compra estrategico utilizado para financiar esos pagos no reembotsados y reducir el gasto sanitario que deben costear las personas con ingresos muy bajos. Es necesario estudiar detenidamente el efecto de esos instrumentos en el acceso a los servicios de salud. Enfoque Se analizan los datos obtenidos sobre el terreno para describir las barreras al acceso, analizar la funcion desempenada por los FIAS y determinar como abordan estos dichas barreras. Contexto local Las dos terceras partes del gasto sanitario total corresponden a pagos directos realizados por los pacientes en el momento de recibir atencion, principalmente cuando se automedican o acuden a la medicina privada. Si bien el sector privado absorbe la mayor parte de los pagos directos, los honorarios cobrados a los usuarios siguen obstaculizando tambien el acceso a los servicios publicos por parte de las personas con muy bajos ingresos. Cambios destacables Los FIAS favorecieron la llegada de nuevos pacientes a los centros publicos y permitieron asi cubrir algunas necesidades sanitarias que no estaban atendidas. No se observaron problemas de estigmatizacion de los pacientes beneficiados por los FIAS, pero muchos de ellos aun tuvieron que pedir dinero prestado para acceder a la atencion de salud. Ensenanzas extraidas Los FIAS son un mecanismo de compra empleado por el sistema de atencion de salud de Camboya que cumple cuatro funciones esenciales: financiacion, apoyo comunitario, garantia de la calidad y dialogo normativo. Dichas funciones corresponden a las barreras principales al acceso a los servicios de salud. EI impacto Iogrado es maximo cuando entra en juego un acuerdo con terceros. Se requiere un entorno normativo solido y propicio para que los FIAS revelen todo su potencial como instrumento activo de adquisicion., Introduction The Cambodian public health-care system is financed through a national budget, donor funding and user fees. However, two-thirds of total health expenditure consists of patients' out-of-pocket spending at the [...]

Byline: Minna Niskanen (1), Matti Reinikainen (2), Ville Pettila (3) Keywords: Intensive care unit; Resource utilization; Length of stay; Outcome assessment; Benchmarking Abstract: Objectives To create a tool for benchmarking intensive care units (ICUs) with respect to case-mix adjusted length of stay (LOS) and to study the association between clinical and economic measures of ICU performance. Design Observational cohort study. Setting Twenty-three ICUs in Finland. Patients A total of 80,854 consecutive ICU admissions during 2000--2005, of which 63,304 met the inclusion criteria. Interventions None. Measurements and results Linear regression was used to create a model that predicted ICU LOS. Simplified Acute Physiology Score (SAPS) II, age, disease categories according to Acute Physiology and Chronic Health Evaluation III, single highest Therapeutic Intervention Scoring System score collected during the ICU stay and presence of other ICUs in the hospital were included in the model. Probabilities of hospital death were calculated using SAPS II, age, and disease categories as covariates. In the validation sample, the created model accounted for 28% of variation in ICU LOS across individual admissions and 64% across ICUs. The expected ICU LOS was 2.53 +- 2.24 days and the observed ICU LOS was 3.29 +- 5.37 days, P < 0.001. There was no association between the mean observed - mean expected ICU LOS and standardized mortality ratios of the ICUs (Spearman correlation 0.091, P = 0.680). Conclusions We developed a tool for the assessment of resource use in a large nationwide ICU database. It seems that there is no association between clinical and economic quality indicators. Author Affiliation: (1) Department of Anesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland (2) Department of Intensive Care, North Carelia Central Hospital, Joensuu, Finland (3) Department of Anesthesiology and Intensive Care, Meilahti Hospital, Helsinki University Central Hospital, Helsinki, Finland Article History: Registration Date: 15/12/2008 Received Date: 19/12/2007 Accepted Date: 08/12/2008 Online Date: 06/01/2009 Article note: Electronic supplementary material The online version of this article (doi: 10.1007/s00134-008-1377-0) contains supplementary material, which is available to authorized users.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/S0140-6736(09)60111-2 Byline: Awad Mataria (a)(b), Rana Khatib (a), Cam Donaldson (c), Thomas Bossert (d), David J Hunter (e), Fahed Alsayed (f), Jean-Paul Moatti (g) Abstract: Attempts to establish a health plan for the occupied Palestinian territory were made before the 1993 Oslo Accords. However, the first official national health plan was published in 1994 and aimed to regulate the health sector and integrate the activities of the four main health-care providers: the Palestinian Ministry of Health, Palestinian non-governmental organisations, the UN Relief and Works Agency, and a cautiously developing private sector. However, a decade and a half later, attempts to create an effective, efficient, and equitable system remain unsuccessful. This failure results from arrangements for health care established by the Israeli military government between 1967 and 1994, the nature of the Palestinian National Authority, which has little authority in practice and has been burdened by inefficiency, cronyism, corruption, and the inappropriate priorities repeatedly set to satisfy the preferences of foreign aid donors. Although similar problems exist elsewhere, in the occupied Palestinian territory they are exacerbated and perpetuated under conditions of military occupation. Developmental approaches integrated with responses to emergencies should be advanced to create a more effective, efficient, and equitable health system, but this process would be difficult under military occupation. Author Affiliation: (a) Institute of Community and Public Health, Birzeit University, Birzeit, occupied Palestinian territory (b) Department of Economics, Faculty of Commerce and Economics, Birzeit University, Birzeit, occupied Palestinian territory (c) Institute of Health and Society, Newcastle University, Newcastle-upon-Tyne, UK (d) Department of Global Health and Population, Harvard School of Public Health, Cambridge, MA, USA (e) Centre for Public Policy and Health, School of Medicine and Health, Durham University, Teesside, UK (f) Ministry of Health, Palestinian National Authority, University of the Mediterranean, Marseille, France (g) Institute of Health and Medical Research (INSERM) and Southeastern Health Regional Observatory (ORS PACA), Research Unit 912 and Faculty of Economics, University of the Mediterranean, Marseille, France

Objective: Older people may act as sensitive indicators of the effectiveness of health systems. Our objective is to distinguish between the effects of socio-economic and behavioural factors and use of health services on urban-rural differences in mortality and health of elderly women. Methods: Baseline and longitudinal analysis of data from a prospective cohort study. Participants were a community-based random sample of women (n=12778) aged 70-75 years when recruited in 1996 to the Australian Longitudinal Study on Women's Health. Measures used were: urban or rural residence in Australian States and Territories, socio-demographic characteristics, health related behaviour, survival up to 1 October 2006, physical and mental health scores and use of medical services. Results: Mortality was higher in rural than in urban women (hazard ratio, HR 1.14; 95% CI, 1.03,-1.26) but there were no differences between States and Territories. There were no consistent baseline or longitudinal differences between women for physical or mental health, with or without adjustment for socio-demographic and behavioural factors. Rural women had fewer visits to general practitioners (odds ratio, OR=0.54; 95% CI, 0.48-0.61) and medical specialists (OR=0.60; 95% CI, 0.55-0.65). Conclusions: Differences in use of health services are a more plausible explanation for higher mortality in rural than urban areas than differences in other factors. Implications: Older people may be the 'grey canaries' of the health system and may thus provide an 'early warning system' to policy makers and governments. Key words: Women's health, mortality, rural health, urban health, health services.

Health professionals from two different clinical settings were asked about their comfort level in dealing with intimate partner violence (IPV). Focus groups and semistructured interviews were used to gather information. Staff in an obstetrics and gynecology setting relatively rich in IPV resources described feeling capable dealing with IPV. The staff in a general medicine setting dedicated to women's health but without a focus on IPV and with fewer supports described discomfort and difficulty dealing with IPV. Presence of systemic prioritization of and resources for IPV were described as contributing to the confidence in addressing the issue. Other necessary elements identified included (a) on-site resources, (b) adequate time, (c) focused IPV training, and (d) a team or systemic approach. Keywords: intimate partner violence; screening; barriers to care; health care system; coordinated care

Objectives. We sought to compare quality of diabetes care by insurance type in federally funded community health centers. Method. We categorized 2018 diabetes patients, randomly selected from 27 community health centers in 17 states in 2002, into 6 mutually exclusive insurance groups. We used multivariate logistic regression analyses to compare quality of diabetes care according to 6 National Committee for Quality Assurance Health Plan Employer Data and Information Set diabetes processes of care and outcome measures. Results. Thirty-three percent of patients had no health insurance, 24% had Medicare only, 15% had Medicaid only, 7% had both Medicare and Medicaid, 14% had private insurance, and 7% had another insurance type. Those without insurance were the least likely to meet the quality-of-care measures; those with Medicaid had a quality of care similar to those with no insurance. Conclusions. Research is needed to identify the major mediators of differences in quality of care by insurance status among safety-net providers such as community health centers. Such research is needed for policy interventions at Medicaid benefit design and as an incentive to improve quality of care. (doi:10.2105/AJPH.2007.125534)

Objectives. We examined associations between patient characteristics and self-reported difficulties in accessing mental health and general medical care services. Methods. Patients were recruited from the Continuous Improvement for Veterans in Care-Mood Disorders study. We used multivariable logistic regression analyses to assess whether predisposing (demographic characteristics), enabling (e.g., homelessness), or need (bipolar symptoms, substance abuse) factors were associated with difficulties in obtaining care, difficulties in locating specialty providers, and forgoing care because of cost. Results. Patients reported greater difficulty in accessing general medical services than in accessing psychiatric care. Individuals experiencing bipolar symptoms more frequently avoided psychiatric care because of cost (odds ratio [OR]=2.43) and perceived greater difficulties in accessing medical specialists (OR=2.06). Homeless individuals were more likely to report hospitalization barriers, whereas older and minority patients generally encountered fewer problems accessing treatment. Conclusions. Need and enabling factors were most influential in predicting self-reported difficulties in accessing care, subsequently interfering with treatment dynamics and jeopardizing clinical outcomes. Efforts in the Department of Veterans Affairs to expand mental health care access should be coupled with efforts to ensure adequate access to general medical services among patients with chronic mental illnesses. (doi:10.2105/AJPH.2007.131318)

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/S0140-6736(09)60110-0 Byline: Rajaie Batniji (a), Yoke Rabaia (b)(c), Viet Nguyen-Gillham (b)(d), Rita Giacaman (b), Eyad Sarraj (e), Raija-Leena Punamaki (f), Hana Saab (g), Will Boyce (h) Abstract: We describe the threats to survival, development, and wellbeing in the occupied Palestinian territory using human security as a framework. Palestinian security has deteriorated rapidly since 2000. More than 6000 Palestinians have been killed by the Israeli military, with more than 1300 killed in the Gaza Strip during 22 days of aerial and ground attacks ending in January, 2009. Israeli destruction and control of infrastructure has severely restricted fuel supplies and access to water and sanitation. Palestinians are tortured in prisons and humiliated at Israeli checkpoints. The separation wall and the checkpoints prevent access to work, family, sites of worship, and health-care facilities. Poverty rates have risen sharply, and almost half of Palestinians are dependent on food aid. Social cohesion, which has kept Palestinian society intact, including the health-care system, is now strained. More than US$9 billion in international aid have not promoted development because Palestinians do not have basic security. International efforts focused on prevention of modifiable causes of insecurity, reinvigoration of international norms, support of Palestinian social resilience and institutions that protect them from threats, and a political solution are needed to improve human security in the occupied Palestinian territory. Author Affiliation: (a) Department of Politics and International Relations, University of Oxford, Oxford, UK (b) Institute of Community and Public Health, Birzeit University, Birzeit, occupied Palestinian territory (c) VU University Medical Centre, Amsterdam, the Netherlands (d) Center for the Victims of Torture, Minneapolis, MN, USA (e) Gaza Community Mental Health Programme, Gaza City, occupied Palestinian territory (f) Helsinki Collegium for Advanced Studies, University of Tampere, Tampere, Finland (g) Faculty of Education, Queen's University, Kingston, ON, Canada (h) Social Program Evaluation Group, Queen's University, Kingston, ON, Canada

Purpose: A Web-based education/support intervention for caregivers of stroke survivors was developed. A prospective, descriptive design was used to identify caregivers' reported reasons for stroke survivors' health care service use [...]

Greetings to all my friends and colleagues, from a very green Edinburgh in mid-winter. As I complete my first six months in this new position, it is helpful to reflect [...]

Objective: To estimate the contribution of health care to health gain, and to ethnic and socio-economic health inequalities, in New Zealand over the past quarter century. Method: Amenable and all-cause mortality rates by ethnicity and equivalised household income tertile from 1981-84 to 2001-04 were estimated from linked census-mortality datasets (the New Zealand Census-Mortality Study). Amenable mortality (deaths under age 75 from conditions responsive to health care) was defined using a classification recently developed for use in Australia and New Zealand. The contribution of health care to the observed improvement in population health status was estimated by the ratio of the difference in amenable to the difference in all-cause mortality over the observation period. Results: Trends in amenable causes of death were estimated to account for approximately one-third of the fall in mortality over the past quarter century, for the population as a whole and for all income and ethnic groups except Pacific peoples, for whom there was no reduction in amenable mortality. In 2001-04, amenable causes accounted for approximately one quarter of the mortality gap between all ethnic groups compared to the European/Other reference. Discussion: Our finding provides one indicator of the social impact of health care over this period. More importantly, that Pacific peoples seem to have benefited less than other ethnic groups calls for urgent explanation. Also, our finding that amenable causes account for about one quarter of current mortality disparities, clearly indicates that improvement in access to and quality of health care for disadvantaged groups could substantively reduce health inequalities. Key words: amenable mortality, trends, New Zealand

Improving access to culturally-appropriate services and enhancing responses to the needs of older people from black and minority ethnic backgrounds were among the aims of the National Service Framework for Older People (NSFOP) that was introduced in England in 2001. Progress in meeting the aims of the NSFOP was evaluated by a mid-term independent review led by the Healthcare Commission, the body responsible for regulating health-care services in England. This paper reports the consultation with older people that underpinned the evaluation. It focuses on the views and experiences of older people from black and minority ethnic (BME) groups and of the staff that work in BME voluntary organisations. A rapid appraisal approach was used in 10 purposively selected local councils, and plural methods were used, including public listening events, nominal groups and individual interviews. In total 1,839 older people participated in the consultations and 1,280 (70%) completed a monitoring form. Some 30 per cent defined themselves as of a minority ethnic background. The concerns were more about the low recognition of culturally-specific and language needs than for the development of services exclusively for BME older people. KEY WORDS--black and minority ethnic older people, UK National Service Framework for Older People, consultation, health services, social care.

Mental health services have been routinely underutilized. This study investigated the influence of parents' gender, race, and psychopathology on perceived barriers and attitudes toward mental health utilization for themselves and for their children. A unique contribution of this study is the examination of father, mother, and child factors influencing service utilization from the parents' perspective. A total of 194 African American and Caucasian parents were recruited from the community to participate. Parents completed measures on barriers and attitudes toward treatment for themselves and for their children, history of mental health service utilization for themselves and for their children, and their own current psychological symptoms. Results indicated that 36.3% and 19.4% of parents and children, respectively, had used mental health services during their lifetime. Parents perceived fewer barriers and had more positive attitudes toward seeking services for their children than for themselves. Race and gender differences were found in parents' perceptions of barriers and attitudes toward treatment. Furthermore, barriers, attitudes, and psychopathology predicted parents' plans for future utilization of mental health services. The clinical implications of this study and directions for future research are discussed. Keywords: barriers, attitudes, race, gender, psychopathology

Purpose: The purpose of this study was to examine racial/ethnic differences in the relationship between functional disability and the use of health care services in a nationally representative sample of older adults by using the Andersen behavioral model of health services utilization. Design and Methods: The study used 12 years of longitudinal data from the Health and Retirement Study (1992-2004), a nationally representative sample of community-dwelling adults older than 50 in 1992 (N = 8,947). Nonlinear multilevel models used self-reported health care service utilization (physician visits and hospital admissions) to predict racial/ethnic differences in disability (activities of daily living and mobility limitations). The models also evaluated the roles of other predisposing (age and gender), health need (medical conditions and self-rated health), and enabling factors (health insurance, education, income, and wealth). Results: Blacks and Latinos utilizing physician visits and hospital admissions were associated with significantly more activity of daily living disability than Whites (p < .001). Blacks utilizing physician visits (p < .001) and hospital admissions (p < .05) and Latinos utilizing hospital admissions (p < .05) were associated with more mobility disability than Whites. Other predisposing, health need, and enabling factors did not account for these racial/ethnic differences. Implications: Nationally, health care use for Blacks and Latinos was associated with more disabilities than for Whites after we accounted for predisposing, health need, and enabling factors. The findings suggest that improving health care quality for all Americans may supersede equal access to health care for reducing ethnic and racial disparities in functional health. Key Words: Activities of daily living, Mobility, Health disparities, Andersen behavioral model of health services utilization, Multilevel modeling

Purpose: The Veterans Affairs or VA health care system is in the process of significantly expanding home health care (HHC) nationwide. We describe VA HHC use in 2003 for all VA HHC users from 2002; we examine whether VA utilization across a broad spectrum of services differed for a sample of VA HHC users and their propensity-score-matched controls. We also consider crossover between the VA and Medicare. Design and Methods: This is a retrospective study using propensity score and stratified analysis to control for selection bias on observable characteristics. We examined the full cohort of 2002 VA HHC users (n = 24,169) and a 2:1 sample of age- and race-based nonusers (n = 53,356). Utilization measures included VA and Medicare outpatient, inpatient, nursing home, and hospice use, as well as VA home-based primary care, respite care, and adult day health care. Results: VA HHC users had a higher absolute probability of outpatient use by around 3%, of inpatient use by 12%, and nursing home use by 6% than their propensity-score-matched controls. Implications: Veterans who used HHC services had a higher rate of VA service use in the subsequent year than controls did, even after we adjusted for differences in observed health status, eligibility advantages, and supplemental insurance status. High utilization for VA home health users spilled over into high Medicare utilization. Key Words: Formal home care, Health care services use, Stratified analysis, Veterans

Purpose: This article estimates the effects of alcohol consumption on self-reported overall health status, injuries, heart problems, emergency room use, and hospitalizations among persons older than the age of 65. Design and Methods: We analyzed data from the first wave of the National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative study. We used multivariate regression and instrumental variables methods to study the associations between alcohol consumption (current drinking, binge drinking, and average number of drinks consumed) and several indicators of health status and health care utilization. Results: Alcohol consumption by women was associated with better self-perceived health status, improved cardiovascular health, and lower rates of hospitalizations. We detected no significant negative or positive associations for older men. Implications: These findings suggest that light to moderate alcohol use by older women may have beneficial health effects. Experimental trials, however, are needed to more rigorously assess the potential benefits of alcohol use by elders due to the inherent biases of observational studies. Key Words: Alcohol consumption, Health care utilization, Self-perceived health status, Health benefits, Selection bias

Objectives: The aim of this study was to assess social inequality in use of dental services by examination of visiting for relief of pain and receipt of extractions. Methods: Data were collected in the period of 2004-06, from a stratified clustered sample of Australians aged 15+ years, using a computer-aided telephone interview. Analysis was restricted to n=10,099 dentate adults. Results: Visiting for relief of pain varied by age, country of birth, education and income with lower odds (Odds ratio, 95% CI) among 55-74 (0.43, 0.35-0.54) and 75+ year-olds (0.22, 0.15-0.33) compared to the 15-34 year-olds, lower odds among Australian-born persons (0.82,0.69-0.98) compared to those born overseas, higher odds for those with no post-secondary education (1.31, 1.07-1.61) and with TAFE, trade or other qualifications (1.34, 1.09-1.66) compared to university qualified, and for those in the Conclusions: The results indicate social inequality in provision of dental services and suggest an urgent need for the dental profession and governments to address this inequality. Key words: accessability, dental care, socio-economic factors, adults.

This study examines and explains the gender disparity in health despite rapid modernization in South Korea where the social structure is still based on traditional gender relations. A nationally representative sample of 2897 men and 3286 women aged 25-64 from the 2001 Korean National Health and Nutrition Examination Survey was analyzed. Health indicators included self rated health and chronic disease. Age-adjusted prevalence was computed according to a gender and odds ratios (OR) derived from logistic regression. Percentage changes in OR by inclusion of determinant variables (socio-structural, psychosocial, and behavioral) into the base logistic regression model were used to estimate the contributions to the gender gap in two morbidity measures. Results showed a substantial female excess in ill-health in both measures, revealing an increasing disparity in the older age group. Group-specific age-adjusted prevalence of ill-health showed an inverse relationship to socioeconomic position. When adjusting for each determinant, employment status, education, and depression contributed the greatest to the gender gap. After adjusting for all suggested determinants, 78% for self rated health and 86% for chronic disease in excess OR could be explained. After stratifying for age, the full model provided a complete explanation for the female excess in chronic illness, but for self rated health a female excess was still evident for the younger age group. Socio-structural factors played a crucial role in accounting for female excess in ill-health. This result calls for greater attention to gender-based health inequality stemming from socio-structural determinants in South Korea. Cross-cultural validation studies are suggested for further discussion of the link between changing gender relations and the gender health gap in morbidity in diverse settings. Keywords: Social determinants South Korea Health inequalities Gender differences Modernization Social change

A qualitative analysis was completed on sermons from ten African-American preachers of the Pentecostal faith to determine if and how they discussed depressive symptoms, based on the statements they made in the pulpit about depression, sadness, and grief. Messages surrounding views about mental health treatment were also explored. Findings illustrate that African-American Pentecostal preachers in the study preached sermons suggesting that long term depression is a weakness, and promoted the notion that 'saints don't cry'. Also, their sermons were dispassionate about psychotropic medication use and the use of psychiatrists. Implications for mental health practice with African-American preachers and parishioners are discussed. Keywords Depression * Mental-health service utilization * African-American * Pastors * Church * Pentecostal

Background. To date, there has been little empirical evidence about the relationship between service use and risk-adjusted functional outcomes among the frail, chronically ill elderly population. The Program of All-Inclusive Care for the Elderly (PACE) offers a unique model within which to investigate this relationship. We examine variation in the risk-adjusted utilization of acute, rehabilitative, and supportive services in PACE, and assess whether use of these services is associated with risk-adjusted functional outcomes. Methods. The analytical sample included 42,252 records for 9853 individuals in 29 programs, over 3 years. Outcome was measured as change in functional status. Service use was assessed for hospital and nursing home admissions, day center attendance, therapy encounters, and personal home care. Mixed regression, generalized estimating equation (GEE) log-linear Poisson models and bootstrap procedures were used. Results. We examined the marginal effect of the five services on functional status over time, having controlled for each program's risk-adjusted use of services and functional status of their enrollees. We observed a statistically significant association between hospital admissions and functional status. Sites using more hospital care had worse functional outcomes. We found no other significant relationship between functional change and service use. However, correlations between program-level measures showed that sites providing more day center care and more therapy had significantly fewer hospital admissions. Conclusions. Findings suggest that programs with high hospital use may do well to re-examine and adjust the intensity of day center care. Greater focus on service provision in this setting may enhance care coordination and lead to reductions in hospitalizations, better outcomes, and cost savings. Key Words: PACE--Frail elderly persons--Service use--Functional outcome.

Objectives. We examined the association between race and hepatitis C virus (HCV) evaluation and treatment of veterans in the Northwest Network of the Department of Veterans Affairs (VA). Methods. In our retrospective cohort study, we used medical records to determine antiviral treatment of 4263 HCV-infected patients from 8 VA medical centers. Secondary outcomes included specialty referrals, laboratory evaluation, viral genotype testing, and liver biopsy. Multiple logistic regression was used to adjust for clinical (measured through laboratory results and International Classification of Diseases, Ninth Revision, codes) and sociodemographic factors. Results. Blacks were less than half as likely as Whites to receive antiviral treatment (odds ratio [OR] = 0.38; 95% confidence interval [CI] = 0.23, 0.63). Both had similar odds of referral and liver biopsy. However, Blacks were significantly less likely to have complete laboratory evaluation (OR = 0.67; 95% CI = 0.52, 0.88) and viral genotype testing (OR = 0.68; 95% CI = 0.51, 0.90). Conclusions. Race is associated with receipt of medical care for various medical conditions. Further investigation is warranted to help understand whether patient preference or provider bias may explain why HCV-infected Blacks were less likely to receive medical care than Whites. (doi: 10.2105/AJ PH.2007.113225)

Purpose: The purpose of this study was to identify relationships between medical, functional, economic, oral health, social, religious, and psychological factors and under-eating in homebound older adults. The focus of the study was on identifying potentially modifiable factors amenable to social and behavioral interventions. Design and Methods: A total of 230 homebound older adults who were currently receiving home health services participated in interviews in their homes using a questionnaire to assess eating behaviors and factors that could possibly affect those eating behaviors. Interviewers measured height and weight, and participants completed three 24-hr dietary recalls. Results: The mean age of participants was 79.1 years. The sample comprised 78% women and 38% African Americans. We found that 70% of participants were under-eating, defined as not consuming enough calories to maintain their current body weight. Participants who were at higher risk of under-eating included men, those receiving either infrequent care or very frequent care by a caregiver, those who had been hospitalized prior to receipt of home health services, and those with a higher body mass index. Implications: Findings from the study have implications for both practice and policy. Experts must develop evidence-based interventions targeted at under-eating in this particularly vulnerable and growing population of homebound older adults. This study provides an initial foundation for the development of targeted evidence-based behavioral nutritional interventions that are noninvasive and cost effective. Key Words: Under-eating, Undernutrition, Nutrition policy

The competence of doctors and the quality of medical care they provide in low-income countries are particularly low. The poor have access to lower-quality care than the rich in both the public and private health sectors.

This supplemental issue of the Journal of Homosexuality presents research that explores a variety of health care issues encountered by lesbian, gay, bisexual, transgender and intersex (LGBTI) population groups in the United States over the 10-year period from 1993 to 2002. Topics include access to health care, utilization of care, training of medical and mental health providers, and the appropriate preparation of clinical offices and waiting areas. Authors used a variety of community-based public health research methods, including participant and provider surveys and retrospective chart reviews of patients, to develop this body of research, providing a recent-historical perspective on the complex health care and health-related needs of sexual and gender minorities. Particularly for transgender and intersex populations, the state of research describing their health care needs is in its infancy, and much remains to be done to design effective medical and mental health programs and interventions. KEYWORDS. Gay, lesbian, bisexual, transgender, intersex, sexual minorities, ethics in public health, health disparities, HIV/AIDS

The aims of this paper are to review the health status of British nationals living on the Costa Blanca in the Province of Alicante, Spain, and to examine their access to health-care services. A sample of 155 of those that spent over three months a year in the area was interviewed. The results for those aged 45 or more years have been compared with those of the Health Survey for England 2003, the British Household Panel Survey 2004, the National Health Survey for Spain 2003, and the Spanish Household Panel Survey 2000. British nationals resident on the Costa Blanca appear to have a similar health profile to the Spanish and the British populations, and score higher than Spaniards and the British home population on some indicators: they have, for example, fewer mobility problems and a more positive perception of their state of health. These findings are consistent with the 'healthy migrant hypothesis'. The Valencia Region Health Service provides health-care services to 62 per cent of this population. The total number of British residents' visits to a general practitioner is approximately the same as that of their Spanish neighbours. As for admissions to hospital, British residents on the Costa Blanca show trends similar to the population of the United Kingdom. The use of private health-care is relatively high, compared to the Spanish and the British populations. KEY WORDS--health care, health status, migration, expatriates, British citizens, Spain.

Relatively few studies have looked specifically at the experiences and needs of African American women who are survivors of domestic violence. This study sought to find out from African American survivors (a) what their experience was with various community entities and (b) how they feel race may have affected these experiences. Results indicate a great deal of dissatisfaction with the services received as they attempt to escape and/or stay away from their abusive partners. This dissatisfaction was in large measure due to lack of cultural competence. Implications for service and suggestions for community entities are presented. Keywords: intimate partner violence; African American survivors; community response; needs assessment

Older individuals are given low priority compared to other age groups in many societies and geriatric care is not welldeveloped in many countries. With the global trend in population aging, the increasing number of older adults can be expected to challenge already-fragile health care facilities. Health care systems vary greatly from one country to another. Based on common research interests and through an educational exchange program between the University of Groningen (the Netherlands) and the American University of Beirut (Lebanon), a project was started to compare the Dutch and Lebanese health care delivery systems for older individuals, demonstrate their strengths and pitfalls, and draw from their resemblance and differences pivotal conclusions leading to positive change. In particular we examined the nursing homes, geriatric medicine and insurance coverage, and pension plans of both countries. Keywords: Older adults; Health care systems; Nursing homes; The Netherlands; Lebanon

Objective: To quantify the contribution of health care to ethnic and socio-economic inequalities in health in New Zealand in 2000-02, using the concept of 'amenable' mortality (deaths at ages 0-74 years from causes responsive to health care). Data sources and Methods: Mortality data for 2000-02 were provided by the New Zealand Health Information Service and 2001 Census population data were provided by Statistics New Zealand. The classification of ICD-10 codes as amenable or non-amenable used in the Australian and New Zealand Atlas of Avoidable Mortality (2006) was adopted. Ethnicity was categorised as Maori, Pacific or European/Other. Socio-economic position was measured using a Census-based small area deprivation index, the NZDep2001. Mortality rates were standardised for age by the direct method for the ethnic group comparisons, and for both age and ethnicity for the deprivation group comparisons. The contribution of health care to health inequality was then quantified as the ratio of the difference in standardised amenable mortality rates to the difference in standardised total mortality rates (in the age group 0-74 years) between relevant groups. Results: Amenable causes of death were estimated to account for 27%, 34%, 33% and 44% of the total mortality disparity (0-74 years) for Maori males, Maori females, Pacific males and Pacific females respectively, relative to their European/Other counterparts (adjusting for age). The corresponding proportions for the 'deprived' population relative to the 'non-deprived' population were 26% (males) and 30% (females), adjusting for age and ethnicity. Conclusions: Amenable causes of death made a substantial contribution to differences in mortality in the 0-74 year age range between ethnic and socio-economic groups in New Zealand in 2000-02, ranging from 26-44% depending on the group. Key words: health, inequality, amenable morality, New Zealand

Background. Issues around end-of-life health care have attracted increasing attention in the last decade. One question that has arisen is whether very elderly individuals receive overly aggressive treatment at the end of life. The purpose of this study was to address this issue by examining whether health care use at the end life varies by age. Methods. The study included all adults 65 years old or older who died in Manitoba, Canada in 2000 (N = 7678). Measures were derived from administrative data files and included location of death, hospitalizations, intensive care unit (ICU) admission, long-term care (LTC) use, physician visits, and prescription drug use in the last 30 days versus 180 days before death, respectively. Results. Individuals 85 years old or older had increased odds of being in a LTC institution and also dying there than did individuals 65-74 years old. They had, correspondingly, lower odds of being hospitalized and being admitted to an ICU. Although some statistically significant age differences emerged for physician visits, the effects were small. Prescription drug use did not vary by age. Conclusions. These findings indicate that very elderly individuals tended to receive care within LTC settings, with care that might be considered aggressive declining with increasing age. However, health care use among all age groups was substantial. A critical issue that needs to be examined in future research is how to ensure quality end-of-life care in a variety of clinical contexts and care settings for individuals of all ages.